Provider Demographics
NPI:1508485160
Name:LAZOS, JESSICA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAZOS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 TYLER BROWN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-2568
Mailing Address - Country:US
Mailing Address - Phone:931-216-1817
Mailing Address - Fax:
Practice Address - Street 1:215 DUNBAR CAVE RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8850
Practice Address - Country:US
Practice Address - Phone:931-542-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3054224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty